Chronic osteomyelitis is difficult to treat and eradicate completely. It is characterized by infected dead bone within scarred soft tissue. Treatment requires long-term antibiotics as well as extensive surgical debridement to remove all infected and dead bone. Multiple surgical procedures may be needed to eliminate residual infection by removing bone sequestra and draining sinus tracts. Even with aggressive treatment, complications like reinfection, joint stiffness, and limb deformity are common.

1. CHRONIC OSTEOMYELITIS

2. Osteomyelitis
Osteomyelitis is defined as an inflammation
of the bone caused by an infecting
organism.
The infection may be limited to a single
portion of the bone or may involve the
marrow, cortex, periosteum, and the
surrounding soft tissue.

3. CLASSIFICATION
Duration of symptoms
 (acute, subacute, and chronic)
 Mechanism of infection
 exogenous or hematogenous.
Based on the host response to the disease.
 pyogenic or nonpyogenic

4. When the duration of osteomyelitis is more
than 3 weeks, its called ch. Osteomyelitis.
Causes-
1.Trauma causing open fractures.
2.Post operative.
3.Osteomyelitis with chronic etiology-
- TB
- Brodie’s abscess.
- Fungal osteomyelitis.

5. CHRONIC OSTEOMYELITIS
Chronic osteomyelitis
is difficult to eradicate
completely.
 Systemic symptoms
may subside, but one
or more foci in the
bone may contain
purulent material,
infected granulation
tissue, or a
sequestrum

6. PATHOLOGY
Necrosis. stage of new bone formation
involucrum. with sequestrum inside, with a
persistent discharging sinus.  pus from bone
escapes through multiple hole in involucrum

7. CHRONIC OSTEOMYELITIS
The hallmark of chronic osteomyelitis is
infected dead bone within a compromised
soft-tissue envelope.
The infected foci within the bone are
surrounded by sclerotic, relatively
avascular bone covered by a thickened
periosteum and scarred muscle and
subcutaneous tissue.
 This avascular envelope of scar tissue
leaves systemic antibiotics essentially
ineffective.

8. Chronic osteomyelitis
 Secondary infections are common, and sinus
track cultures usually do not correlate with
cultures obtained at bone biopsy.
 Multiple organisms may grow from cultures
taken from sinus tracks and from open
biopsy specimens of surrounding soft tissue
and bone.

9. CLINICALLY
- Pain, swelling.
- Discharging sinus.
- Bone thickening.
- Deformity.
- Joint stiffness.
- Shortening of limb,
- Pathological fracture.
- Sinus track malignancy.

10. Cierny and Mader Staging System
MedullaryEndosteal
disease
 TypeI Medullary
Endosteal disease
 II Superficial Cortical
surface infected because of
coverage defect
 III Localized Cortical
sequestrum that can be
excised without
compromising stability
 IV Diffuse Features of I,
II, and III plus mechanical
instability before or after
débridementl sequestrum

11. D/D
1.TB osteomyelitis- watery discharge.
- previous h/o TB, sinus with undermined
margin with blue colour.
2. Ewing's sarcoma- A primary malignant tumor of
bone, usually arising as a central tumor in long bone.
(biopsy)
3. Soft tissue chronic infection. (X-ray)

12. Diagnosis
Clinical, Laboratory, and Imaging studies.
The “gold standard” is to obtain a biopsy
specimen for histological and microbiological
evaluation of the infected bone.

13. Diagnosis
Clinical examination
- Integrity of the skin and soft tissue
-areas of tenderness
-assess bone stability
- neurovascular status of the limb.

14. Laboratory investigations
Blood counts
ESR
CRP

15. Imaging studies
Plain radiographs
 cortical destruction
 periosteal reaction
 Sequestrum deformity
 Sclerotic bone

16. Sinography

17. CT Scan
 Cortical bone and surrounding soft tissues
and is especially useful in identifying
sequestra.

18. MRI
The extent of the pathological insult by
showing the margins of bone and soft-tissue
edema.
Well-defined rim of high signal intensity
surrounding the focus of active disease seen
(rim sign).

19. TREATMENT
Supportive treatment .
Antibiotics – to prevent spread.
Surgery – sequestretomy + saucerization
[cannot be eradicated without surgical intervention]

20. Sequestrectomy and Curettage

21. Sinus tracks can be injected with methylene blue 24
hours before surgery to make them easier to locate
and excise.

22.  TECHNIQUE
 • Expose the infected area of bone and excise all sinus tracks
completely.
 • Incise the indurated periosteum and elevate it 1.3 to 2.5 cm on
each side.
 • Use a drill to outline a cortical window at the appropriate site
and remove it with an osteotome.
 • Remove all sequestra purulent material and scarred and necrotic
tissue . If sclerotic bone seals off a cavity within the medullary canal
open it into the canal in both directions to allow blood vessels to
grow into the cavity.

23.  After removing all suspicious matter, carefully excise the overhanging
edges of bone and avoid leaving a cavity or dead space. If a cavity cannot be
filled by the surrounding soft tissue, a local muscle flap or a free tissue
transfer can be used to obliterate the dead space.
 If there is a nonunion present with any bony instability the bone must be
stabilized preferably with an Ilizarov-type external frame.
 If possible close the skin loosely over drains and ensure that no excessive
skin tension is present. If closure is impossible, pack the wound open
loosely or apply an antibiotic bead pouch and plan for delayed closure or
skin grafting at a later time.
 Appropriate antibiotics should be used before during and after the
operation.

24. AFTER TREATMENT
 6-week course of intravenous antibiotics is
given after surgical débridement
 The limb is splinted until the wound has
healed, and then it is protected to prevent
pathological fracture

25. Methods described to eliminate
dead space
(1) Bone grafting with primary or secondary closure
(2) Antibiotic polymethyl methacrylate (PMMA)
beads as a temporary filler of the dead space before
reconstruction
(3) Local muscle flaps and skin grafting with or
without bone grafting
(4) Microvascular transfer of muscle, myocutaneous,
osseous, and osteocutaneous flaps
(5) The use of bone transport (Ilizarov technique).

26. Open Bone Grafting (Papineau
technique)
STAGE I: DéBRIDEMENT
STAGE II: GRAFTING (autogenous cancellous bone
grafting)

 STAGE III: WOUND COVERAGE

27. Papineau Technique
 STAGE I: DéBRIDEMENT
 STAGE II: GRAFTING
 STAGE III: WOUND COVERAGE
In some cases, spontaneous epithelialization
otherwise,
 skin grafts
 myocutaneous flaps
 muscle pedicle flaps
 free flaps requiring microvascular anastomosis.

28. COMPLICATIONS
Joint stiffness.
Shortening.
Muscle contracture.
Pathological fracture.
Sinus track malignancy.
Amyloidosis.

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